S 0869 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
jBUII,DING
OF CUPERTINO BDII.DING-ELELT'RICAI, TERM[]NO,
DIVISION APPLICA'FIONMERMIT PI.UARSG-MECHANIIV. S 0869
BUILDINGPROJECT IDENTIFICATION
NGADDRESSSANITARY NO. APPLICATION SUBMIIIAL UAfE
20 �� y' AME: PHONE: CD RAC(() NAMIL� �• :F lVit�:r LIC NO� NIC CONI ROLA
ARCHITECT/ENGINEER: LIC NO: )R]iSS: ❑
ONTACT: PHONE, BUIIDING PERMIT INFO
:Yoe, @�il k 4 G C,) 9 Z 7 Z,5-{i j ❑ ConsulEanl Fces Paid by Applicant(Initial) EC PLUhte MECH
3 b J U ❑ '�a ❑
I.ICENSFD CONTRACfOR;S DECLARATION QTY. ELECTRIC PERMIT FEF
I hereby suite,But 1 in lermis d mule,pine;.....of Chap c,9(commencing JOB DESCRIPTION
O�Z won sennn nlw)of Di�omm�3anne Ba,ines,and Prore„ion,code.and my becnsc t,
RESIDENTIAL:
4100 PERMIT ISSUANCIi
F�.. in full force and aTcn. ❑SPDWI. [I KITCHEN REMODELFZU LucClas�Cnntmct`- 9— APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
rn Q 1 ARCHITECTS DF,CI,ARATION ❑MULTI-UNIT ❑STRUCTURAL
ZONZ I undersand my pimosibull beused an mblNrecnrdc UP TO
MODIFICATION
UP TO 200 AMPS
❑INTIiRIOR ❑CHIMNGY REPAIR
F4LW Licea,rd Pr000wmal 201-IWnAMPS IMPROVEMENT E]SWIMMING POOIS
C� � OWNER-BUILDER UECLARA'f10N OVER BIBLE AMPS ❑BATH REMODCU P IR s140/
h10 TION
C t 6 I hereby alGrm In.,I am cWrd,d from the Cmamectors Lierroc Law for the
IEZ
X 3 6 V following reason.(Section 70315,Business and Profusion.Code:Any city or county SIGNS ELECTRICAL ❑OTHER
ly y which requlms a permit it,cea,mar,after,improve,demolish or repair an,,mr,ame
F�-O4 prim to its issuance,also requites the applicant for.such permit to file a signed statement SPEC]AL CIRCUI'f/MISC.
y— that he is licensed punuvnt 1.he pre,mmmsofthe Cormad e,License Law(Chapter 9
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POIL INST. COMMERCIAL:
d q m W that he is exempt therefrom:ted the basis for the alleged exemption.Any violation of Cl NEW BLDG/ADDITION ❑DEMOLITION
W m Steins 7031.5 by any applicant for a permit subjeae lire applicant to a civil penalty of POWER iVICES El TENANT [I FOOD S12RVICE
not more than five hand.]dollars($500).
IMPROVEMENT
QQl.as owner ofthe property,nr my employecswith x'agc,asrhei.snle compensainn, SW MING I'OOhIiL1iC'1'RIC
($�F will do lire work,and the structure is not intended proffered for hale(Se e.7( 'Business El OTHER
413 m and Professinm Cade The Contractors License Law does nit apply am am tuner of TT-S HGl-FIX'TUkE
-. property who builds or improves thereon,and who does inch work hiroelf or through
his own employees,provided that such improvement,me not intended o.of need Ins EW RE PIAL EL SQ FI'. C7
side.If.however,the Inildingnr in......career in sold within one year of completion,the SQ.FT.17LO<lR�Ri..1A I $ISQ
frd o .FT
owner-builder will have the burden oproving(bat he did act hard nrprov,for pur- V' 4Y
put of sole.).
(]1.as owner of the property,am excluovely contracting with licensed contractor to TOTAL,: NOV �]Qa I1
incrust the prujcn Dean.,,(Sec.9044,Dean ,and ProfessioTh
ns Coder e Cnntmcmrs Li- N2+ E17T
cease law does not apply to an owner of property who builds of imprms,mentor,and QTY. PLUM BIN ER ITT FEE
who contracts for such projects with a commnar(q pn
licensed livam to the Contra.....'.
Lleeaoe Law' PERMIT ISSU CE • C1 U- surrr IIIVU
❑I am exempt under See. .B&P C for reason
Owner Date ALTER-DRAN VIN - ATIiR(RAI VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PR 'ECT.DEVICE
1 hereby effort under penalty of perjurynuc al'the Collw'ing deelt rati...:
Kim. maintain a Certificate of Consento self-incum for Workers Copes- DRAINS-I'LOOK,ROOF.AREA,CONI. STORIES TY PE CIINSTRUCTIOt
mien,as provided for by Section 3700 of the Lahr Cade,for the perfonnnncc m the
work far which this permit is mard i IIXI'URI-%-PER TRAP
[ 1 have and will maintain Workers Compensation liforemse.its required by Section
3700 of the labor Code,for the performance mfthe work for which Nis permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.CROUP AI'N
My Worker�sdCn pc -tin In more. aad Pof. cher arc: GAS-EA.SYSTF.MAVT:R4fF,A)
/ Center S�jf'€+afi(/kJ (` n m-PolicyN'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRI,WASTE INTERCEPTOR
BUILDING DIVISION PEFS
(This section nmdnat bcumpincJ il'deficient is Torose hundred dollar($IIXI) GREASETRAP
or less) I PLANCf{ECK PER.
I ceriry that fn lire pxrfamanee of the work for which this permit is issued.Isbdi SEWER-SANITARY-STORM EA.200 FE
not employ any person in any mann..so as to become sib ml to the Wurkcfs'Compen- ENERGY FEE
zZ cation Law,of California.Dote WATER HEATER W/VITWATLECTR
10 Applicant GRADING FEE
y� NOTICE T'O APPLICANT If,after inking this Certificate of ExcurP e.you should WATER SYS]EMFTR EAT]NO
become subject rte the Worker's Compenmun r provisions a]the labor Core.you muss SOILS FEE
forthwith comply with such provisions(it this pc mit shall be deemed revoked. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RGSIDEN('IAL PLM1I6. SQ,FT, PAID
UQ IheaM1y affirm lM19l there isnmraWctlan leoJingagency for thepMonnancc of Uun Be •iptM
U. P the wmk for which Nis Extend i,issued(Sec.3097.civ.CJ
O U Lender's Name TOTAL:
} Lcmlers Address
I codify that I have read this application and state that the above information is BUILU]NG PEE ��
F" V0.i mreclJ agate nm a,mp]y whh:ul my and county oadmvnces and.arc laws rclmin&r' QTY. MECHANICAL PERMIT FEE
UZ huildingcnnsntetin .read hereby radau<xc,cs'cnwtivesof this city memeruorde, SEISMIC IEE
ahove-memioned pn,pcny for ins,tion purposes. PERMIT ISSUANCE(We)ogles mm wve,indemnify and keep harmless the City of Ctmedire.,ains ELECTRIC FEE 1, nil Ono
liabilities.judgments.costs and expenses which may in anyway ufeme again,said City ALTER ORADDT(IMECH.
in ..sequence of the granting of this permit. PLUMBING IEE
APPLICANT UNDERSTANDS AND WILL CO PLY WITH ALL NON-POINT AIR HANDLING UNITTf010.000CFM)
SOURC REC .ATIONS. MECHANICALNT
L/�/'
AIR HANDLING UNI'1'((IVER 10.000CPM) CONS'TRUCIION TAX
Signumm of ApplivmFCmmvmr Dom IiXHAUS'T HOOD(W/DUC) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or(mum building occupant Nom nt handle ha<allou.s muturial I IEAI'ING UNIT('I O 100.000 BTU)
us define)by(be Cuptnino Municipal Cade,Chapter 9.12,and the Health and Safely
Calc,Section 25532(x)^ HEATING UNIT((OVER 100.000 BTU)
Ed Vex KN.
VENTILATION FAN(SINGLE RICSID) PAID
Aim W]II the vpplicrnt or future building occupant use equlpnanl or devices which Date Receipt a
coal nmwmirear,m defined by the play Area Air Quality Management BOILER-COMP 13lIP OR IW.gw BTU)
'TOTAL:
DixWetP BOILER-COMP(OVER 100.00OBTU)
L
�ffNa
rved the ha-m ao mmeral,mmimments under Chapmr6695ofthe Cali AIRCON'DITIONER ISSUANCE DATE
&Safety Cover,Seeder,25505,25533 and 25534.1 mederst.d that if the NEW RESIDENTIAL MECH. SQ.FT.
buildinged entered,have a mann[,that II i,my responsibility m notify the occupant
merll,wcetriormnf 'icoriwd at
Date TOTAL: ISSUED BY:
OFFICE